Contract Pharmacy Details

LARRY'S FAMILY PHARMACY
CH100180 HEALTH WEST INC

Covered Entity Details

Entity Name

HEALTH WEST INC

Subdivision Name

HEALTH WEST - ADMINISTRATION OFFICES

Type

HRSA-Funded Health Center

340B ID

CH100180

Entity Address

500 S 11th AVE
POCATELLO, ID 83201-4835

Grant Number

H80CS00321

Participating Start Date

4/1/2004

Last Recertification Date

2/12/2025

Pharmacy Details

Pharmacy Name

LARRY'S FAMILY PHARMACY

Pharmacy Address

217 SOUTH STATE
PRESTON, ID 83263

Pharmacy Comments

Contract Details

Approval Date

10/14/2015

Contract Begin Date

1/1/2016

Carve-In Effective Date

Contract Comments

Contract Termination Date
Termination Reason

1/1/2017
Ownership change

Contacts

Covered Entity Signing Official

Mindy Benedetti, CEO
(208) 232-7862 Ext: 1120

Contract Pharmacy Representative

Larry Durrant, Owner
(208) 852-0163

Signed By Date

10/14/2015